Successful soft tissue reconstruction of the foot and ankle is challenging and often needs an interdisciplinary approach, especially when composite defects are present. This chapter provides a coherent concept to treat cases of severe skin and soft tissue damage of the foot and ankle. A functional and anatomical subdivision of the foot and ankle region is proposed depending on its pressure distribution, soft tissue quality, zones of shear and the structural anatomy. A treatment algorithm, highlighted by two clinical cases, is presented considering common and well established local, regional and micro-surgical reconstructive options to restore maximum sensibility, motor function and aesthetics.